Michael’s choice

Fraser stayed indoors, where caregivers, during their daily sojourns, would help change his diapers and tend to his needs. His wife, Ann, provided comfort, both to his failing body and his mind, still scarred from an abusive childhood.

“Why should I continue on?” Fraser asked, sitting inside his rented walk-up, just a few steps from Forest Hill mansions.

“My body is falling apart. I don’t want to spend the next five or six years living like this…I’d rather die in my own bed than just die neglected, alone in a long-term care facility.”

Burdened with liver disease, regular fainting attacks, falls, incontinence and an inability to walk, he qualified earlier this year to end his life under Canada’s Medical Assistance in Dying legislation.

On July 2, surrounded by friends, family and a reporter, Fraser lay in his bed and extended his arm to receive a fatal cocktail of drugs administered by his Toronto physician, Dr. Navindra Persaud.

He was not terminal. But a constellation of factors – intractable disease, poverty, childhood sexual trauma, mental health challenges and the option of an assisted death – made him question whether his life was one worth continuing to live. For Fraser, death was ultimately preferrable.

The same social safety net that failed him in life would enable him to die on his own terms.

Last year, the federal government expanded eligibility to include Canadians who aren’t actually dying, removing the requirement that applicants have a fatal or terminal condition that would make their natural death “reasonably foreseeable.”

The controversial change has contributed to a jump in the number of Canadians ending their lives upon request.

Fraser was among them.

Persaud, Fraser’s long-time family doctor, has been grappling with his own role in his patient’s death.

“Professional standards were met, it’s legal, but I do feel guilty. I’m conflicted about it…Someone you know and care about is dead. As a doctor, there is doubt. Could I have done something differently to reduce the suffering?”

One of the reasons Persaud said he became a family doctor was a desire to serve vulnerable people like Fraser, level the playing field, give them the same chances as everyone else.

“When I encounter a patient who has a very sad story like Michael’s, I have a higher responsibility to do whatever is possible to help. For sure, it makes today harder to inject those lethal medications when you know everything he's been through…It just seems so unfair.”

Last year, 10,064 Canadians ended their lives through medical assistance, the highest-ever total in the history of the program and a third of all cases since the program started in 2016.

In the weeks leading up to his final breath, Fraser shared with reporters the story of his life, and his decision to end it.

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Born in Montreal in the late 1960s, Fraser was only three when his father died suddenly, leaving the family with one fewer caregiver and desperate financial need.

By age six, his mother had remarried, introducing to the household a man who would go on to frequently abuse Fraser both physically and sexually.

“He got drunk in the middle of the night and would drag me out of bed and do things to me,” Fraser recalled. “My brothers knew what was going on, but they turned their faces to the wall.”

He said his mother knew as well, but because Fraser was biologically the product of an affair between his father and another woman, she never considered him as one of her own. She never did anything to protect him from her husband’s abuse, Fraser said.

The most basic care was hard to come by. At times, unfed by those meant to attend to his needs, a young Fraser ate cat food.

At age 10, he recalled, he ate mysterious red berries off the bushes near his house, believing them to be poisonous. It would be the first of numerous attempts to end his life.

“I guess it’s a good thing, but I’m really bad at suicide.”

When he was 11, his stepfather took him to a fishing camp with other adult men, where he was to be the “entertainment.”

“I had these grown men abusing me for four days,” he said.

Five decades later, he still grappled with the abuse – and how it was allowed to happen.

“I’ll wake up at night and the smell is so strong in my nostrils, the sweat and the alcohol and tobacco of the other men,” he said.

“The system failed me as a kid. It didn’t really take care of me.”

Fraser began drinking at a young age, starting with a swig of liquor as he helped clean up after a party his parents hosted in Montreal. He continued to drink frequently throughout his life to silence the haunting echoes of his stepfather’s voice, he said.

It led to chronic liver problems.

“The voices are saying, ‘you don’t belong here…You’re a dirty little boy, you always have been,’” Fraser said. “After a while, you start taking it to heart.”

Ann, Fraser’s wife, said she could often tell when it struck him, even in his sleep.

“He starts shaking,” she said. “He jumps. I just know he’s getting hit by something. I put my hand on his shoulder and say, ‘I’m here. It’s a dream. It’s a nightmare. I got you.’ [It happens] all the time.”

Fraser’s childhood abuse continued until he dropped out of school and left home at age 13. He found an apartment and worked in a warehouse loading Montreal Gazette newspapers into trucks each morning. By 15, still without a driver’s licence, he was promoted to a delivery driver, carrying newspapers to depots across the city.

In 1980, he moved to Thornhill, where he floated through low-wage warehouse and transportation jobs until he was admitted to hospital for his mental health struggles.

“What happened in 1995 is that everything that ends up inside me just explodes,” he said. “I just had been keeping it down for so long that I don't know what triggered it.”

He was diagnosed with post-traumatic stress disorder and anxiety, held in hospital for three days and then released into Toronto streets with no jacket or shoes, in the dead of winter.

The same day, police found him walking up Yonge Street, teddy bear in hand. Fraser said he wanted to see the North Pole. He spent the next three months back in hospital.

To Fraser, it was an early lesson in how the healthcare system moves people in need through a cycle from desperation to temporary care and back.

Through the health challenges, there was also poverty.

Fraser lived much of his life on the Ontario Disability Support Program (ODSP). At the end of his life, it provided $1,100 per month. His rent ate up $974 of that for the same apartment where he lived for 25 years.

With no elevator, the second-floor unit imprisoned him in recent years as he could no longer walk without assistance. He was often trapped there, forced to stay inside for weeks at a time. He didn’t have the money to afford a more accessible place.

In the final weeks of Fraser’s life, reporters met many of those encircling him during afternoon visits at his apartment. Each was wrestling – often visibly – with the murky questions raised by his choice.

“It’s heartbreaking to me that the system let him down in a way that he felt there was no other option,” said a Toronto paramedic who dropped into the apartment one afternoon to check on Fraser, part of a program that monitors patients who frequently rely on 9-1-1.

“I’ve gotten to know Michael well. He’s just such a kind, positive guy. It’s been very challenging to think this is the outcome.”

By July 2, the day Dr. Persaud came to the walk-up with the injection chemicals, Fraser had not been outside the apartment in more than a month.

“There were a number of factors that led to Michael’s decision and I think poverty was one of them. It’s hard to disentangle them all,” Persaud said. “Sometimes poverty is pushing people to MAiD who can be helped by other supports. For sure, I think the fact that he had trouble paying his rent made it harder for him to be in this world.”

Designed as a compassionate legal alternative for those facing life with intractable disease, pain and anguish, MAiD’s adoption in Canada has largely been celebrated as a humane and visionary public policy.

To qualify, candidates like Fraser must have an incurable and debilitating disease and have the application vetted and approved by two physicians.

Agreeing to end the life of a patient remains intimidating, said Persaud. There is no central repository and no list of pharmacies that have the drugs needed for the procedure. So Persaud had to make numerous calls to find a pharmacy able to provide them for Fraser’s death. “One of the drugs needs to be refrigerated so since Thursday it’s been tucked away in my fridge,” he said. “The cloak and dagger aspect of it makes it feel illicit.”

Meanwhile, a growing chorus of critics – including the United Nations – is calling the application of the law a grim solution that provides suicide as a way to avoid falling through Canada's shredded social safety net.

The UN’s special rapporteur on the rights of persons with disabilities, Catalina Devandas-Aguilar, expressed “extreme concern” about MAiD legislation in Canada, concluding that “there is no protocol in place to demonstrate that persons with disabilities deemed eligible for assistive dying have been provided with viable alternatives.”

During visits to care facilities across the country, she said many people with disabilities told her they are being offered a choice between a nursing home or an assisted death.

Last year, UN officials sent a formal letter to the Canadian government warning of human rights violations that could flow from expanding eligibility for assisted death to those who aren’t dying.

“It is not beyond possibility that, if offered an expanded right as per Bill C-7, persons with disabilities may decide to end their lives because of broader social factors such as loneliness, social isolation, and lack of access to quality social services,” it read.

“There is a grave concern that, if assisted dying is made available to all persons with a health condition or impairment, regardless of whether they are close to death, a social assumption might follow (or be subtly reinforced) that it is better to be dead than live with a disability.”

In a written statement, Health Canada said MAiD legislation seeks to support “autonomy and freedom of choice, while rigorously protecting persons who may be vulnerable.”

It is not intended as an option for those lacking adequate social supports, the statement reads.

“There is no evidence that a person would be assessed as eligible for MAiD by two independent practitioners if the assessors had reason to believe that the person’s grievous and irremediable medical condition…could be relieved on a sustained basis by access to reasonable and available treatment and social services.”

It is not known how many assisted suicide seekers struggle with low incomes that hasten the decision to end their lives. Federal data shows about one in four Canadians with disabilities are living in poverty.

The social supports designed to improve the lives of the sick and poor often fall short. Publicly-funded palliative care was only available to about one in six qualifying patients who died in Ontario and Alberta, a recent study found.

In March 2023, MAiD eligibility expands to include those with mental illness as their sole underlying condition. With one in five Canadians experiencing mental health conditions, the upcoming change is sparking new warnings given the chronic underfunding of mental health services.

In recent months, two members of the government’s expert panel on medically assisted dying publicly resigned citing a lack of safeguards to protect vulnerable people.

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Fraser made his decision to end his life over the past Christmas holidays. By the new year, he had built the courage to ask his wife to help.

“He said, ‘it hurts so much. Everything's falling apart. ...Can you help me end it?’” she remembered. “I said to him, ‘I can’t do that. I’m your soulmate.’”

The two met in 2003, at a Forest Hill church where Ann taught Sunday school and Fraser volunteered as a handyman.

It took seven years for Fraser to invite Ann on their first date — to paint an office together.

As the years came and went, Ann continued teaching and Fraser continued to work around the church, where Fraser would say he “cleaned God’s house.”

Fraser left an indelible mark on many of those he met. Rev. Steve Fetter, the minister at Forest Hill United Church, said that for Fraser, the thread through his time with the church was servanthood — a pride in being of help to those around him, to take away what made life worse.

“I don’t think it was just the dirt on the pews that disappeared,” Fetter said. “He showed me what the sanctuary was for.”

By 2020, Fraser’s deteriorating health prevented him from his volunteer work at the church.

In the fall of last year, Ann found Fraser lying in a pool of blood on the floor of their apartment. He had collapsed from a seizure and split his head open.

Fraser’s liver disease was causing fluid to pool in his legs and lower his blood pressure in his upper body and brain, Persaud said.

Ann began having nightmares about “what kind of pieces” she might find him in after returning from work at the end of the day.

“I was already starting to get to the point where I said, he’s not safe at home alone,” she said. “I’d already had this conversation with coordinators, the doctor, social worker, like I don’t know what to do.”

This didn’t make the decision for the pair any easier, but both said with confidence that this was the right course of action for Fraser. Both said their faith helped them gradually find peace with that decision.

“God’s not really good at giving directional points,” she said. “[But] it’s not being stopped, so to me, that is the green light.”

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A few weeks after telling his wife of his plans, Fraser sat across from Persaud, his doctor of over 10 years, fielding questions on whether he was sure of his decision.

The topic of assisted suicide first came up in late 2020, Persaud recalled.

“He talked about not wanting to be around, how much he was suffering and how little he could do. He did talk about killing himself. There was a gradual process in which those conversations transitioned into talking about whether I could assist him.”

On this winter day in 2022, the two discussed the psychological assessment Fraser would have to undergo to meet the government requirements for MAiD.

After Persaud’s assessment, Fraser met with a second physician as well as a Toronto psychiatrist to “disentangle the mental health issues from the physical,” Persaud said.

The physicians concluded Fraser qualified for MAiD based on his liver failure, physical decline and degree of suffering.

But the stark economic realities undermining his mental health and quality of life were deeply woven into Fraser’s reasoning, said Persaud.

“Some of the struggles he talked to me about was this feeling of not being worthy, that he was a burden on society, a feeling that he didn’t belong...There’s a social aspect to poverty, a hierarchy, that affected his psyche. He told me that it did.”

Each day, home care workers visited Michael to check in, change his diaper and make him comfortable. A few days before Fraser’s death, one caregiver who had been making the daily trips to him for several months paused as she prepared to leave him for the last time. There were tears in her eyes.

“Have a good life,” Michael said to her, welling up himself.

She crossed the room and bent down to hug him. After nearly a minute, she rose, wiping her eyes before whispering “goodbye” and closing the door behind her.

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On the appointed day, a small group of guests arrived around 2 p.m.

Persaud was among the first. As he began to prepare, he pulled Fraser aside and asked him, not for the first time: “Are you certain this is what you want to do?”

Fraser confirmed.

Standing in one corner of the small living room was Dorothy Hollingsworth. She had met Fraser as an adult but became a kind of adopted mother to him.

“You couldn't make up anything that would be as awful as the circumstances in which he grew up and to have that kind of upbringing and yet turned into such a fine, kind and thoughtful reflective person who put everybody else ahead of themselves,” she said in an interview.

“[I’m going to miss] my conversations with him and just having his presence and wit. Even in all the struggle in the last years, and especially the last year, that wit was evident…I really treasure him.”

Fetter sat directly in front of Fraser remembering moments of friendship they shared through many years of community service at the church. Near the end of Fraser’s life, the two spoke frequently about this day and what waited for him on the other side.

“A dozen times, he said he didn’t know his faith was strong enough,” Fetter said, his voice breaking. “I hate the way that we make faith into a test…Faith is what we trust in; it gets us through. And he found that … in this community that believed in him when he didn’t believe in himself.”

As the time approached for the procedure, Fraser announced that he would love to have one final beer. But there were none left in the apartment.

A reporter volunteered to get one for him. Ann suggested the closest place was a pub down the street, one of her husband’s favorite spots.

Inside, the reporter asked the server if he could buy a single can of Pabst Blue Ribbon, Fraser’s brand of choice. The server, Gillian Viveiros, grabbed one from the fridge and presented it.

“Is this for Michael?” she asked.

“It is,” the reporter said, pulling out his wallet to pay. “Are you aware of what’s happening?”

She nodded, her face softening.

“It’s on the house.”

Weeks later, Viveiros said it was a simple gesture of respect for the guy everyone in the neighborhood lovingly dubbed “Church Mike.”

“It was sad because he is someone you are going to miss,” she said. “He was a good person. But if it brought him peace and he was ok with his decision, who is anyone to say?”

Back at the apartment, Fraser cracked the beer.

“Two minutes,” he said, looking at Persaud who stood quietly by.

“I’m here for you whenever you’re ready.”

After a moment, one last request.

“I think I’m going to have a cigarette and then we’ll call it a day.”

As he puffed, some last bits of housekeeping: “We have a dozen eggs and some bacon and some peppers in the fridge,” he told the assembled. “You should take it with you so it doesn’t go bad.”

Persaud prepared in the bedroom.

Prior to this case, the 41-year-old physician had performed only a handful of other assisted deaths. While he believes in the relief it can bring to patients in dire need, Persaud is an ambivalent participant in the process.

“I wouldn’t describe myself as a supporter of MAiD,” he said. “I’m a doctor who received a request from a patient and I fulfilled my obligation as a physician.”

It’s a tension that he said remains widespread in the medical profession.

“The vast majority of doctors haven’t done it and don’t want to do it. I thought that I wouldn’t do it when it was first approved. It’s not that I objected to it. It’s just not something I ever anticipated doing when I was training to be a doctor. But things change when a patient you’ve been caring for, for years, is suffering and tells you they want your help in dying.”

Out of principle, Persaud said he does not bill OHIP for the procedure.

“It is an immense privilege to be able to help a person in that way. I don’t feel worthy of it.”

Persaud disappeared into the bedroom while Fraser and the rest spoke in the living room.

Shortly after 3 p.m., the apartment grew quiet. It seemed there was nothing left to say.

“I guess it’s time,” Fraser said, laying the empty beer can down on the table beside him. “I’m going to sleep … I hope there’s something on the other side, but if there’s not then it’s too late now.”

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Inside his bedroom, Fraser lay next to his wife.

At their bedside, Persaud asked one more time: “Are you certain this is what you want to do?”

The last affirmation came back.

Persaud carefully injected the clear liquid into Michael’s arm. The MAiD kit contains three separate medications – a sedative, a deeper anaesthetic and a third medication that either stops the heart or stops breathing.

As Fraser’s pulse and breathing slowed, he fell into unconsciousness. Ann hugged him, weeping quietly. In a broken whisper, her voice repeated, “I love you, I love you.”

Persaud monitored the shallowing breaths.

Michael Fraser died at 3:25 on July 2, 2022.

Persaud walked to a quiet corner to call the provincial coroner. He had to report Fraser's death and arrange for the body to be picked up.

“Five years ago he had a diagnosis of liver sclerosis, further decline two years ago,” Persaud said in staccato patter into his phone as he reported in Fraser’s medical history. “I was providing palliative care as his family physician.”

Ann emerged from the bedroom in tears. She was immediately encircled in hugs, the scrum of bodies shaking in unison amid deep breaths and tears.

“He’s safe now,” she said. “He won’t have to suffer anymore. That’s all I can hope for.”